Clinical Review
Update on age-appropriate preventive measures and screening for Canadian primary care providers Tawnya Shimizu
MN NP-PHC
Manon Bouchard
NP-PHC
Cleo Mavriplis
MD CCFP FCFP
Abstract Objective To summarize the best available age-appropriate, evidence-based guidelines for prevention and screening in Canadian adults. Quality of evidence The Canadian Task Force on Preventive Health Care recommendations are the primary source of information, supplemented by relevant US Preventive Services Task Force recommendations when a Canadian task force guideline was unavailable or outdated. Leading national disease-specific or specialty-specific organizations’ guidelines were also reviewed to ensure the most up-to-date evidence was included. Main message Recommended screening maneuvers by age and sex are presented in a summary table highlighting the quality of evidence supporting these recommendations. An example of a template for use with electronic medical records or paper-based charts is presented.
EDITOR’S KEY POINTS
• Navigating the many different guidelines and recommendations for preventive care can be a daunting task for primary care providers. The authors of this review completed an updated assessment of the best available evidence for prevention and screening among Canadian adults and provide a summary for primary care practitioners.
Conclusion Whether primary care providers use a dedicated preventive health visit or opportunistic preventive counseling and screening in their patient encounters, this summary of evidence-based recommendations can help maximize efficiency and prevent important omissions and unnecessary screening.
U
seful charting tools for preventive care have been published in the past1-4 but not all such resources are regularly updated. There is a lack of recent comprehensive guides to facilitate delivery and charting of appropriate evidence-based • A concise table summarizes age- and primary care. Recommendations for screening come from varisex-appropriate history taking, counseling, ous organizations and are constantly changing, rendering health investigations, and screening tests. Updated promotion and disease prevention a daunting task. Currently, recommendations are provided for cervical navigating the plethora of available information in a search of cancer, prostate cancer, breast cancer, colon prevention guidelines is overwhelming. There is a need for regucancer, and dyslipidemia screening, as well as lar updates through systematic literature reviews. Piecing together weight management. these guidelines into a single summary table for practical use in • Sample charting tools were also created a busy clinical setting simplifies access to information and allows to aid practitioners with documentation at practitioners to provide preventive care in an efficient, evidencededicated preventive health visits or as part of based manner. opportunistic screening. Chronic disease management is an economic burden to the health care system. 5 Savings through prevention have been This article is eligible for Mainpro-M1 This article is eligible for Mainpro-M1 credits. To earn explored by several sources, with emphasis on quality of life and credits. earn credits,and goclick to www.cfp.ca credits, go To to www.cfp.ca on the Mainpro link. increase in years lived.6,7 The Choosing Wisely movement is pub and click on the Mainpro link. licizing the disadvantages of causing harm with tests that are This article has been peer reviewed. not evidence based.8 By facilitating opportunities for prevention Can Fam Physician 2016;62:131-8 through easy access to best-practice guidelines, the incidence of La traduction en français de cet article se trouve chronic disease might decrease, resulting in improved patientà www.cfp.ca dans la table des matières du centred care and savings to the health care system. numéro de février 2016 à la page e64. We performed a review of the literature and created a concise table summarizing the findings, as well as charting tools to aid in Vol 62: february • février 2016
| Canadian Family Physician
•
Le Médecin de famille canadien
131
Clinical Review | Update on age-appropriate preventive measures and screening for Canadian primary care providers documentation. After reading this article, providers will be able to list the evidence-based recommendations for preventive maneuvers in healthy adults of different ages and sexes.
Quality of evidence A review of the literature from 2009 to 2014 was conducted with the assistance of librarians from the Canadian Library of Family Medicine. The PubMed database was searched for articles, in English or French, indexed with a combination of the following sets of medical subject headings: preventive health services, primary prevention, secondary prevention, osteoporosis, prostatic neoplasms, breast neoplasms, colonic neoplasms, hyperlipidemias, mass screening or screening, and practice guidelines as topic or publication type, or guideline, or similar text words or associated text. We also searched the main national guidelines databases CMA Infobase, the US National Guideline Clearinghouse, and the UK National Institute for Health and Care Excellence guidelines for guidelines with combinations of the first 2 sets of terms cited above. The initial search found 289 articles, and articles not relevant to Canadian, office-based preventive primary care and those related to preventive care of children were excluded. A full review of 69 articles was completed using the methods outlined below. The final selection included 40 articles. Published guidelines from many sources relevant to adult preventive care are developed using various methods. The quality of evidence supporting the recommendations was assessed by applying the methods used by Rourke et al4 in the development of the Rourke Baby Record, and the approach used by authors of the Preventive Care Checklist Form2,3 in the development of the last aid for the periodic health examination endorsed by the College of Family Physicians of Canada at the time of writing.3 Both of these groups initially used the old Canadian Task Force on Preventive Health Care (CTFPHC) method of grading recommendations in which recommendations with the highest quality of evidence received an A and those with fair evidence received a B. The US Preventive Services Task Force (USPSTF) is also currently using this method.9 The new CTFPHC adopted the GRADE (grading of recommendations, assessment, development, and evaluation) method in 2010,10 making it challenging to present all recommendations in a unified classification system. The GRADE system11 uses the quality of evidence to evaluate the strength of a recommendation, also taking into account factors in line with family medicine principles: the balance between desirable and undesirable effects, patient values and preferences, and resource allocation. In the GRADE system recommendations are either strong or weak. The only reference found blending these 2 systems was the 2014 update of the Rourke Baby Record.12 For
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the most part they followed the system outlined below, which we adopted. • A recommendation is classified as good (presented in boldface) if according to the older CTFPHC method there is good evidence to recommend the clinical preventive action or if according to the GRADE system it is a strong recommendation. • A recommendation is classified as fair (italic type) if according to the old CTFPHC method there is fair evidence to recommend the clinical preventive action or if according to the GRADE system it is a weak recommendation. • A recommendation is classified as inconclusive or based on consensus (plain type) if according to the older CTFPHC method the existing evidence is conflicting and does not allow for making a recommendation for or against use of the clinical preventive action (although other factors might influence decision making) or if the recommendation is based on consensus only. When organizations mentioned using the old CTFPHC or GRADE systems, the methods used were reviewed to see if the process was modified or adapted. Some sources did not use either of these systems. For these, the methods used were assessed and the recommendations were compared with guidelines from organizations in other countries that target primary care providers, such as the USPSTF or the National Institute for Health and Care Excellence guidelines13 from the United Kingdom. As well, some of these guidelines have been appraised by the CTFPHC.
Main message Based on the literature review, we created tools for use during routine primary care visits to support the delivery of evidence-based preventive care to the adult population. The tools can function as lists summarizing potential appropriate preventive care as well as charting aids to be integrated into medical charts in electronic format or printed out for paper charts. Table 1, the 2015 Primrose Preventive Screening Guidelines, is a 2-page summary of all evidence-based prevention recommendations for adults divided by age and sex.14-43 This table is to be used as a quick reference. Three age categories were used to divide the recommendations for asymptomatic patients without risk factors. The maneuvers that differ for women and men are listed in the lower portion of the table under the headings “Women” and “Men.” For the row “Physical Examination,” only elements found in the review that were evidence-based for a healthy patient with no risk factors are listed. Patients’ concerns and other considerations might influence the type of physical examination done. Six charting tools were created to allow for succinct documentation that can be adapted to paperbased or electronic charting systems. Figure 1 offers an
| Vol 62: february • février 2016
Update on age-appropriate preventive measures and screening for Canadian primary care providers
| Clinical Review
Table 1. The 2015 Primrose Preventive Screening Guidelines: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted. Recommendations Maneuver
Age 21-49 y
Age 50-64 y
AGE ≥ 65 y
• Substances
Smoking14 Alcohol15,16: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances17
Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances
Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances
• Physical activity
150 min/wk moderate or vigorous intensity18 (cannot say more than a few words without pausing for breath)
150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)
150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)
• Diet and nutrition
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt19
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt
• Sun exposure
Protective clothing, sunscreen20
Protective clothing, sunscreen
Protective clothing, sunscreen
• Sexual activity
Safe sex and STI counseling (Screen for chlamydia and gonorrhea annually until age 25 y if sexually active and beyond age 25 y if high risk)
Safe sex and STI counseling if high risk
Safe sex and STI counseling if high risk
History and counseling
21
• Advance directives
Discuss once22
• Supplements
Vitamin D: 400-2000 IU/d Calcium: 1000 mg/d from diet24; 1500-2000 mg/d if pregnant or lactating25
Vitamin D: 1000-2000 IU/d Calcium: 1200 mg/d mainly from diet
Vitamin D: 1000-2000 IU/d Calcium: 1200 mg/d mainly from diet
• Physical examination*
BP,26 height, weight, BMI,27 WC28 If obese (30 kg/m2 ≤ BMI < 40 kg/m2) offer or refer to structured behavioural interventions aimed at weight loss
BP, height, weight, BMI, WC If obese (30 kg/m2 ≤ BMI < 40 kg/ m2) offer or refer to structured behavioural interventions aimed at weight loss
BP, height, weight, BMI, WC If obese (30 kg/m2 ≤ BMI < 40 kg/ m2) offer or refer to structured behavioural interventions aimed at weight loss
23
Investigations and screening tests • Cognitive
Screen if a family member is concerned29; memory complaints should be evaluated and followed to assess progression
• Falls
Ask about trips or falls in past year or fear of falling30
• STI
Gonorrhea and chlamydia31 VDRL, HIV, and HBV if high risk
Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk
Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk
• Diabetes†
Assess HbA1c level if FINDRISC score > 14 32
Assess HbA1c level if FINDRISC score > 14
Assess HbA1c level if FINDRISC score > 14
• Lipid levels‡
Risk assessment32 Screen men ≥ 40 y
Risk assessment Screen women ≥ 50 y or menopausal
Risk assessment
• Vision
19-40 y every 10 y33; 41-49 y every 5 y unless high risk (African American, high myopia, diabetes, or hypertension)
50-55 y every 5 y; 56-64 y every 3 y unless high risk (African American, high myopia, diabetes, or hypertension)
• Colon cancer
• Osteoporosis • Immunizations
§
Td, Tdap, HPV, MMR Pneumococcal, influenza, varicella, polio, meningococcal conjugate36-38
Annually
FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y34
FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y until 75 y
Screen based on risk factors
Screen women and men once > 65 y35
Td, Tdap, pneumococcal influenza, herpes zoster, varicella, polio
Td, Tdap, pneumococcal, influenza, herpes zoster, varicella, polio
Continued on page 134 Vol 62: february • février 2016
| Canadian Family Physician
•
Le Médecin de famille canadien
133
Clinical Review | Update on age-appropriate preventive measures and screening for Canadian primary care providers Table 1 continued from page 133 Recommendations Maneuver
Women • Family planning • Cervical cancer
Age 21-49 y
Folic acid: 0.4-1 mg/d at childbearing age39 Rubella serology40 Start at age 25 y if sexually active,|| every 3 y if results are normal41
Age 50-64 y
AGE ≥ 65 y
Every 3 y if results are normal
Every 3 y if results are normal; stop at age 69 y if 3 normal results in past 10 y Mammogram every 2 y; stop at age 75 y
Mammogram every 2 y 42
• Breast cancer Men • AAA screen
Abdominal ultrasound once at age 65-75 y in patients who have ever smoked 43
AAA—abdominal aortic aneurysm; BMI—body mass index; BP—blood pressure; CVD—cardiovascular disease; FINDRISC—Finnish Diabetes Risk Score; FIT— fecal immunochemical test; FOBT—fecal occult blood test; HbA1c—hemoglobin A1c; HBV—hepatitis B virus; HPV—human papillomavirus; MMR—measlesmumps-rubella; STI—sexually transmitted infection; Td—tetanus and diphtheria; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; VDRL—Venereal Disease Research Laboratory; WC—waist circumference. *WC measurements should be as follows: •
Update on age-appropriate preventive measures and screening for Canadian primary care providers Tawnya Shimizu
MN NP-PHC
Manon Bouchard
NP-PHC
Cleo Mavriplis
MD CCFP FCFP
Abstract Objective To summarize the best available age-appropriate, evidence-based guidelines for prevention and screening in Canadian adults. Quality of evidence The Canadian Task Force on Preventive Health Care recommendations are the primary source of information, supplemented by relevant US Preventive Services Task Force recommendations when a Canadian task force guideline was unavailable or outdated. Leading national disease-specific or specialty-specific organizations’ guidelines were also reviewed to ensure the most up-to-date evidence was included. Main message Recommended screening maneuvers by age and sex are presented in a summary table highlighting the quality of evidence supporting these recommendations. An example of a template for use with electronic medical records or paper-based charts is presented.
EDITOR’S KEY POINTS
• Navigating the many different guidelines and recommendations for preventive care can be a daunting task for primary care providers. The authors of this review completed an updated assessment of the best available evidence for prevention and screening among Canadian adults and provide a summary for primary care practitioners.
Conclusion Whether primary care providers use a dedicated preventive health visit or opportunistic preventive counseling and screening in their patient encounters, this summary of evidence-based recommendations can help maximize efficiency and prevent important omissions and unnecessary screening.
U
seful charting tools for preventive care have been published in the past1-4 but not all such resources are regularly updated. There is a lack of recent comprehensive guides to facilitate delivery and charting of appropriate evidence-based • A concise table summarizes age- and primary care. Recommendations for screening come from varisex-appropriate history taking, counseling, ous organizations and are constantly changing, rendering health investigations, and screening tests. Updated promotion and disease prevention a daunting task. Currently, recommendations are provided for cervical navigating the plethora of available information in a search of cancer, prostate cancer, breast cancer, colon prevention guidelines is overwhelming. There is a need for regucancer, and dyslipidemia screening, as well as lar updates through systematic literature reviews. Piecing together weight management. these guidelines into a single summary table for practical use in • Sample charting tools were also created a busy clinical setting simplifies access to information and allows to aid practitioners with documentation at practitioners to provide preventive care in an efficient, evidencededicated preventive health visits or as part of based manner. opportunistic screening. Chronic disease management is an economic burden to the health care system. 5 Savings through prevention have been This article is eligible for Mainpro-M1 This article is eligible for Mainpro-M1 credits. To earn explored by several sources, with emphasis on quality of life and credits. earn credits,and goclick to www.cfp.ca credits, go To to www.cfp.ca on the Mainpro link. increase in years lived.6,7 The Choosing Wisely movement is pub and click on the Mainpro link. licizing the disadvantages of causing harm with tests that are This article has been peer reviewed. not evidence based.8 By facilitating opportunities for prevention Can Fam Physician 2016;62:131-8 through easy access to best-practice guidelines, the incidence of La traduction en français de cet article se trouve chronic disease might decrease, resulting in improved patientà www.cfp.ca dans la table des matières du centred care and savings to the health care system. numéro de février 2016 à la page e64. We performed a review of the literature and created a concise table summarizing the findings, as well as charting tools to aid in Vol 62: february • février 2016
| Canadian Family Physician
•
Le Médecin de famille canadien
131
Clinical Review | Update on age-appropriate preventive measures and screening for Canadian primary care providers documentation. After reading this article, providers will be able to list the evidence-based recommendations for preventive maneuvers in healthy adults of different ages and sexes.
Quality of evidence A review of the literature from 2009 to 2014 was conducted with the assistance of librarians from the Canadian Library of Family Medicine. The PubMed database was searched for articles, in English or French, indexed with a combination of the following sets of medical subject headings: preventive health services, primary prevention, secondary prevention, osteoporosis, prostatic neoplasms, breast neoplasms, colonic neoplasms, hyperlipidemias, mass screening or screening, and practice guidelines as topic or publication type, or guideline, or similar text words or associated text. We also searched the main national guidelines databases CMA Infobase, the US National Guideline Clearinghouse, and the UK National Institute for Health and Care Excellence guidelines for guidelines with combinations of the first 2 sets of terms cited above. The initial search found 289 articles, and articles not relevant to Canadian, office-based preventive primary care and those related to preventive care of children were excluded. A full review of 69 articles was completed using the methods outlined below. The final selection included 40 articles. Published guidelines from many sources relevant to adult preventive care are developed using various methods. The quality of evidence supporting the recommendations was assessed by applying the methods used by Rourke et al4 in the development of the Rourke Baby Record, and the approach used by authors of the Preventive Care Checklist Form2,3 in the development of the last aid for the periodic health examination endorsed by the College of Family Physicians of Canada at the time of writing.3 Both of these groups initially used the old Canadian Task Force on Preventive Health Care (CTFPHC) method of grading recommendations in which recommendations with the highest quality of evidence received an A and those with fair evidence received a B. The US Preventive Services Task Force (USPSTF) is also currently using this method.9 The new CTFPHC adopted the GRADE (grading of recommendations, assessment, development, and evaluation) method in 2010,10 making it challenging to present all recommendations in a unified classification system. The GRADE system11 uses the quality of evidence to evaluate the strength of a recommendation, also taking into account factors in line with family medicine principles: the balance between desirable and undesirable effects, patient values and preferences, and resource allocation. In the GRADE system recommendations are either strong or weak. The only reference found blending these 2 systems was the 2014 update of the Rourke Baby Record.12 For
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Canadian Family Physician • Le Médecin de famille canadien
the most part they followed the system outlined below, which we adopted. • A recommendation is classified as good (presented in boldface) if according to the older CTFPHC method there is good evidence to recommend the clinical preventive action or if according to the GRADE system it is a strong recommendation. • A recommendation is classified as fair (italic type) if according to the old CTFPHC method there is fair evidence to recommend the clinical preventive action or if according to the GRADE system it is a weak recommendation. • A recommendation is classified as inconclusive or based on consensus (plain type) if according to the older CTFPHC method the existing evidence is conflicting and does not allow for making a recommendation for or against use of the clinical preventive action (although other factors might influence decision making) or if the recommendation is based on consensus only. When organizations mentioned using the old CTFPHC or GRADE systems, the methods used were reviewed to see if the process was modified or adapted. Some sources did not use either of these systems. For these, the methods used were assessed and the recommendations were compared with guidelines from organizations in other countries that target primary care providers, such as the USPSTF or the National Institute for Health and Care Excellence guidelines13 from the United Kingdom. As well, some of these guidelines have been appraised by the CTFPHC.
Main message Based on the literature review, we created tools for use during routine primary care visits to support the delivery of evidence-based preventive care to the adult population. The tools can function as lists summarizing potential appropriate preventive care as well as charting aids to be integrated into medical charts in electronic format or printed out for paper charts. Table 1, the 2015 Primrose Preventive Screening Guidelines, is a 2-page summary of all evidence-based prevention recommendations for adults divided by age and sex.14-43 This table is to be used as a quick reference. Three age categories were used to divide the recommendations for asymptomatic patients without risk factors. The maneuvers that differ for women and men are listed in the lower portion of the table under the headings “Women” and “Men.” For the row “Physical Examination,” only elements found in the review that were evidence-based for a healthy patient with no risk factors are listed. Patients’ concerns and other considerations might influence the type of physical examination done. Six charting tools were created to allow for succinct documentation that can be adapted to paperbased or electronic charting systems. Figure 1 offers an
| Vol 62: february • février 2016
Update on age-appropriate preventive measures and screening for Canadian primary care providers
| Clinical Review
Table 1. The 2015 Primrose Preventive Screening Guidelines: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted. Recommendations Maneuver
Age 21-49 y
Age 50-64 y
AGE ≥ 65 y
• Substances
Smoking14 Alcohol15,16: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances17
Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances
Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances
• Physical activity
150 min/wk moderate or vigorous intensity18 (cannot say more than a few words without pausing for breath)
150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)
150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)
• Diet and nutrition
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt19
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt
Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt
• Sun exposure
Protective clothing, sunscreen20
Protective clothing, sunscreen
Protective clothing, sunscreen
• Sexual activity
Safe sex and STI counseling (Screen for chlamydia and gonorrhea annually until age 25 y if sexually active and beyond age 25 y if high risk)
Safe sex and STI counseling if high risk
Safe sex and STI counseling if high risk
History and counseling
21
• Advance directives
Discuss once22
• Supplements
Vitamin D: 400-2000 IU/d Calcium: 1000 mg/d from diet24; 1500-2000 mg/d if pregnant or lactating25
Vitamin D: 1000-2000 IU/d Calcium: 1200 mg/d mainly from diet
Vitamin D: 1000-2000 IU/d Calcium: 1200 mg/d mainly from diet
• Physical examination*
BP,26 height, weight, BMI,27 WC28 If obese (30 kg/m2 ≤ BMI < 40 kg/m2) offer or refer to structured behavioural interventions aimed at weight loss
BP, height, weight, BMI, WC If obese (30 kg/m2 ≤ BMI < 40 kg/ m2) offer or refer to structured behavioural interventions aimed at weight loss
BP, height, weight, BMI, WC If obese (30 kg/m2 ≤ BMI < 40 kg/ m2) offer or refer to structured behavioural interventions aimed at weight loss
23
Investigations and screening tests • Cognitive
Screen if a family member is concerned29; memory complaints should be evaluated and followed to assess progression
• Falls
Ask about trips or falls in past year or fear of falling30
• STI
Gonorrhea and chlamydia31 VDRL, HIV, and HBV if high risk
Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk
Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk
• Diabetes†
Assess HbA1c level if FINDRISC score > 14 32
Assess HbA1c level if FINDRISC score > 14
Assess HbA1c level if FINDRISC score > 14
• Lipid levels‡
Risk assessment32 Screen men ≥ 40 y
Risk assessment Screen women ≥ 50 y or menopausal
Risk assessment
• Vision
19-40 y every 10 y33; 41-49 y every 5 y unless high risk (African American, high myopia, diabetes, or hypertension)
50-55 y every 5 y; 56-64 y every 3 y unless high risk (African American, high myopia, diabetes, or hypertension)
• Colon cancer
• Osteoporosis • Immunizations
§
Td, Tdap, HPV, MMR Pneumococcal, influenza, varicella, polio, meningococcal conjugate36-38
Annually
FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y34
FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y until 75 y
Screen based on risk factors
Screen women and men once > 65 y35
Td, Tdap, pneumococcal influenza, herpes zoster, varicella, polio
Td, Tdap, pneumococcal, influenza, herpes zoster, varicella, polio
Continued on page 134 Vol 62: february • février 2016
| Canadian Family Physician
•
Le Médecin de famille canadien
133
Clinical Review | Update on age-appropriate preventive measures and screening for Canadian primary care providers Table 1 continued from page 133 Recommendations Maneuver
Women • Family planning • Cervical cancer
Age 21-49 y
Folic acid: 0.4-1 mg/d at childbearing age39 Rubella serology40 Start at age 25 y if sexually active,|| every 3 y if results are normal41
Age 50-64 y
AGE ≥ 65 y
Every 3 y if results are normal
Every 3 y if results are normal; stop at age 69 y if 3 normal results in past 10 y Mammogram every 2 y; stop at age 75 y
Mammogram every 2 y 42
• Breast cancer Men • AAA screen
Abdominal ultrasound once at age 65-75 y in patients who have ever smoked 43
AAA—abdominal aortic aneurysm; BMI—body mass index; BP—blood pressure; CVD—cardiovascular disease; FINDRISC—Finnish Diabetes Risk Score; FIT— fecal immunochemical test; FOBT—fecal occult blood test; HbA1c—hemoglobin A1c; HBV—hepatitis B virus; HPV—human papillomavirus; MMR—measlesmumps-rubella; STI—sexually transmitted infection; Td—tetanus and diphtheria; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; VDRL—Venereal Disease Research Laboratory; WC—waist circumference. *WC measurements should be as follows: •
